Medicaid expansion is chugging forward — and there's nothing Republicans can do about it

As any Republican will tell you, the Affordable Care Act, aka ObamaCare, has been an utter disaster, a complete catastrophe, the destroyer of liberty, ruination of countless lives, and slayer of hope. After all, did it not fail to turn insurance companies into models of concern and caring? Did it not fail to reverse the medical inflation that has been a constant practically forever? Is it not true that under the ACA you can still not only get sick, but even die? Thanks, Obama.

But seriously, the ACA has fallen short of what it could be in a number of ways. Yet there's one success story from the law that's so dramatic, even some Republicans can't fight against it anymore, even if they'd rather not talk about it: the expansion of Medicaid. In fact, it's looking like the most consequential part of the law, even more than the outlawing of denials of coverage for pre-existing conditions.

Consider this recent development: The Republican governor and Republican legislature in Oklahoma, about as red a state as they come, is now considering accepting the Medicaid expansion. Why? It's because the state is facing a budget crisis that could lead to draconian cuts in its existing Medicaid program. As The Associated Press reported, "A bust in the oil patch has decimated state revenues, compounded by years of income tax cuts and growing corporate subsidies intended to make the state more business-friendly." They need the money, so all those anti-government Republicans are looking to the federal government to bail them out.

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And if in the process they have to allow thousands of the working poor citizens of their state to get coverage? They don't like it, but it's a price they'll be willing to pay.

And I'm not being sarcastic, because the Republican states that have held out against the Medicaid expansion have made it clear that they're not just indifferent to the plight of their uninsured, they'd much rather have a poor family go without insurance than to see them get that insurance from the government. After all, you had the federal government offering to pick up nearly the entire tab to insure a huge swath of the population — people who made too much to qualify for the previously stingy program, but whose incomes are too low to get subsidies on the ACA exchanges. In Oklahoma today, parents can only get Medicaid if their incomes are less than 42 percent of the poverty level (that's the princely sum of $10,206 for a family of four). But the state said no, even though the feds were offering to insure all those people for free, and even though studies by non-partisan groups have found that states save money when they accept the expansion. Which means states like Oklahoma were willing to pay extra for the privilege of not insuring their citizens. But I guess it was worth it to give Barack Obama the finger.

If Oklahoma follows through on accepting the expansion, that would bring the number of holdout states down to 18, all of them governed completely or in part by Republicans. Even with these holdouts, the program has expanded dramatically; today there are 16 million more people receiving Medicaid than before the law was passed.

As a result (and also because of the other provisions of the ACA), last year the proportion of the American population without health insurance fell below 10 percent for the first time in history. In some places the decline has been particularly dramatic; New Mexico, for instance, cut its rate of uninsured in half, mostly due to Medicaid. And the security that comes from being insured can have a variety of benefits; one recently released study found that Medicaid coverage meant fewer unpaid bills and less household debt for the recipients.

For the Republicans who opposed the ACA so vehemently, there's nothing to celebrate in millions more people being covered by government insurance. And the truth is, getting everyone covered isn't even one of their goals for the health care system. You can see it in the answers they give when you ask what happens to all those people when they succeed in repealing the ACA and return to the status quo ante. The answer is: nothing. They'll just be out of luck if they can't afford the vaguely-defined "patient-centered" policies Republicans hope for, where the magic of market forces that failed for so long are supposed to suddenly provide low-cost, high-quality insurance for all.

And that's the political problem that Republicans in Congress won't admit to in public, but understand in private. You can hold 50 repeal votes knowing that it won't happen as long as there's a Democrat in the White House. But actually repealing the ACA would mean tossing tens of millions of people off the coverage they have. Remember what a stink Republicans raised because after the ACA took effect a far smaller number of people had to switch plans? Now think about the political backlash when so many millions find themselves with no coverage at all.

It's one thing to prevent large numbers of people from getting insurance, as so many conservative states have done. But it's something else entirely to take away the insurance people already have. That's why it won't happen even if Republicans got full control of the government. They might pass something they call "repeal," but it wouldn't actually be repeal; it would be designed to minimize the political damage while making a few changes here and there.

This is one of the reasons Republicans have been so adamantly opposed to the ACA: They know from experience that once you give people a government benefit, it becomes awfully hard to unwind. Republicans would like nothing more than to privatize Medicare, but they've never been able to, because the program is just too darn popular the way it is. And while Medicaid recipients aren't as organized (and likely to vote) as those on Medicare, there's only so many of them you could toss off the rolls without getting yourself in a whole lot of trouble. The Congressional Budget Office projects that by 2026, a quarter of the under-65 population will be on Medicaid or CHIP, the program for low-income children. Just try taking an axe to a program used by that many Americans.

So over the next few years, we're likely to see more and more states giving in and finally accepting the Medicaid expansion. It's just too good a deal to pass up. And the result will be millions more people with the security of coverage, access to care, and more stable family finances. In the meantime, there are still millions of uninsured people who could get covered if only their state governments would hurry up and do what they're going to do eventually anyway.